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Friday, 31 May 2013

When the Ads Don’t Work

Anne Cooke and Dave Harper 

Is your mind made up about mental illness?
This picture may dispel any doubts.
Photo: Giovanni Cassanese
 
It’s a sobering thought that, for many people who use mental health services, other people’s reactions cause more distress than their original problems.   And attitudes may even be getting worse.  A recent report from the Department of Health found that whereas in 1997, 92% of people questioned agreed that ‘we need to adopt a more tolerant attitude towards people with mental illness’, in 2011 only 86% thought that we need to be more tolerant.   Worryingly, young people appeared to be the most prejudiced.

Relatively static attitudes to mental health stand in contrast to the changes there have been in attitudes about ethnicity and sexuality (we currently have a conservative Prime Minister advocating same-sex marriage).  It’s even more surprising given the effort that has gone into anti-stigma campaigns.  For example you may have seen the recent tube posters or TV ads from the government sponsored Time to Change campaign.   So what’s the problem?  Perhaps part of the answer is what campaign ads actually say. Or what they don’t. 

 Traditionally, public education campaigns about mental health have aimed to reduce stigma.  The assumption is that stigma is caused by people not recognising that mental health problems are ‘illnesses like any other’.   For Time to Change, as our colleague John McGowan recently noted, they are ‘as real as a broken arm.   A key assumption here is that unless distress is seen as part of an illness, people will blame sufferers for their own problems. Much better then to be genuinely sick.

We’re not sure about these underlying assumptions.  Firstly, the very idea of stigma is problematic in that it individualises and medicalises what may be an issue of prejudice.  We don’t talk about the stigma of being a woman, or of being black; we talk, quite rightly, about sexism and racism.  

What about the idea that discriminatory attitudes are based on ignorance?   Many anti-stigma campaigns have aimed to increase so-called ‘mental health literacy’– i.e. education about different mental illnesses.    Notable examples of this approach have included Every Family in the Land and Defeat Depression, both led by the Royal College of Psychiatrists. Considerable amounts of money have been invested into such campaigns. However, even their advocates have been forced to admit that there has been little effect.  If anything, things have got worse.  We think that the reason for this lies in the third assumption. Reviewing the evidence, John Read and colleagues found that viewing emotional distress as ‘an illness like any other’ actually increases prejudice and discrimination.  For example, in one study based on Stanley Milgram’s famous electric shock obedience experiments, participants who were told that someone had a mental illness opted to give them more electric shocks than if the person’s problems were described in more everyday language*.     The study’s authors suggest that presenting problems as an ‘illness’ has the effect of making them seem mysterious and unpredictable, the people experiencing the problems as ‘almost another species’.

So if the traditional approach isn’t working, what’s the alternative?  In recent years two related approaches have gained ground.  The first draws on an idea from the wider disability movement, namely the ‘social model’ of disability. This proposes that, rather than the problem for people with physical disabilities being the actual impairment, most difficulties lie in the way society organises itself. The classic example is putting stairs everywhere.  While this model has its limits, these kinds of ideas were influential in the 1995 Disability Discrimination Act, and led to widespread changes, at least in our buildings.  Within the mental health field commentators like Liz Sayce have been influential in applying this model.  Mad Pride is a colourful example of an approach that says it’s Society’s role to change.  This is not simply a romantic notion that we can wish distress away by challenging discrimination.  While some people experiencing unusual and exceptional experiences want to be liberated, others may find the experiences distressing and seek some form of help.  What both groups agree on is that discrimination is a major problem.   

The second approach is what you might call the psychosocial one.  There is increasing evidence that even the most severe mental health problems are not the result simply of faulty genes or brain chemicals. They may also be a natural and normal response to the terrible things that can happen to us.  As our colleagues John Read and Nick Haslam have put it ‘bad things happen and can drive your crazy’.  To many people this is just common sense.  Unlike the illness approach, it makes people’s experiences seem more understandable, enabling people to empathise more. 

So we have at least two alternatives to the ‘illness like any other’ approach:  a focus on ending societal discrimination against people with mental health problems; and viewing distress as a response to negative life experiences.  Although Time to Change does not promote a medicalised approach we think it has missed an opportunity to challenge not only our attitudes but something much more fundamental: whether there are people who are ‘normal’ and people who are ‘mentally ill’ , or whether we’re all in this together.

*For those unfamiliar with Milgram’s experiment the ‘shocks’ were fake. Those asked to administer them were not made aware of this until after the experiment had concluded.

Anne Cooke is a Principal Lecturer, Department of Applied Psychology, Canterbury Christ Church University

Dave Harper is a Reader in Clinical Psychology, University of East London

7 comments:

  1. I've always wondered about TTC (and about that photo!) Interesting that the research suggests that campaigns like this may not be effective.

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  2. I have suffered stigma and feel that TTC is ineffective as the popular press/media is always a stronger. Stereotypes of crazed characters out of horror films all add to the Social Construction of an average service user. Also people like Stephen Fry have sanitized/normalized real distress and oppression.

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  3. I too suffer stigma and the medical profession are also very prejudiced and not in the least bit honest.

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  4. It's interesting to note that people who have used mental health services and engaged with the Time to Change Campaign have had negative experiences of doing so. Our organisation was approached in relation to evaluating the impact of our involvement in the Media arm of the campaign when we used participatory video production to make films which documented the experiences of our members.
    We fed back to them that a purely quantitative approach in language that was of a high order and did not reflect the cultural or lived experience of our members would not do and that what was needed was a mixed methodology with qualitative input. We didn't even receive a response to our comments from the Institute of Psychiatry who had been commissioned to undertake the evaluation. We contributed to a number of publications in Mental Health Today recently which explain a number of complaints and criticisms shared by people from under represented groups and communities.

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  5. I believe that moving forward is a really difficult challenge and the attempt to reduce stigma and discrimination which the TTC campaign represents does have some positive features which critics often gloss over.
    Of course, the individualisation and medicalisation of distress is a serious matter, so what perhaps we could say is that within the state/civil society complex one could pour our entire GDP into the task of altering attitudes towards mental health and it would make no tangible difference.
    Therefore, in my view, trying to raise awareness, commence awkward conversations and spearhead the direct message that something has to alter are positive although necessarily limited aims. Jumping on the bandwagon for the purposes of derailing it is in nobody's interests. Critics who engage with the campaign only to point out it's limitations may aswell join the stigmatisers and discriminators openly, in my humble opinion. Mum's the word when a well-meaning friend is trying to help.
    I do like your discussion of two alternative models. I mean no offence to your efforts and personally see the ever-growing issues which present themselves as being to do with a 'distinct' area we refer to as mental health as representing a major prescient challenge to the current political economic orthodoxies of our time.

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  6. "mental illness" versus "more everyday language". Thanks to mental health awareness campaigns such as TTC, "mental illness" has become part of everyday language. I'd wager that were some-one to survey the general public about their perceived levels of mental health literacy, quite a lot of people would think they know quite a bit about mental health and illness. For example most people know, for a fact, that spurious "one in four" statistic.
    Young people feel particularly informed as they are the target, at least here in Ireland, of the bulk of the campaigns. I can't for the life of me understand why we are so keen to educate teenagers about something on which there is so little scientific, or other, consensus and why we persist in relaying "facts" that are increasingly being discovered to be misconceptions.
    http://stepstowardsthemountain.blogspot.ie/2014/04/we-need-to-talk-about-mental-health.html

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